Alameda Oaks Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Corpus Christi, Texas.
- Location
- 1101 S Alameda, Corpus Christi, Texas 78404
- CMS Provider Number
- 455687
- Inspections on file
- 36
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Alameda Oaks Nursing Center during CMS and state inspections, most recent first.
A resident with respiratory failure, tracheostomy, dependence on supplemental O2, hemiplegia, and a persistent vegetative state, who required maximum assistance with all ADLs and could not be reliably understood, was observed in bed without a call light within reach; the device was clipped behind the resident on the wall. The resident’s care plan called for a specialized call device that was easier to operate, and facility policy required call lights to be accessible to residents in bed, with nursing to determine an alternative if the resident could not use the standard system. An LVN and CNA who had recently repositioned the resident acknowledged the expectation that call lights be within reach for all residents but could not explain why it was not, and the DON confirmed the same expectation.
A resident admitted with type 2 diabetes mellitus and other chronic conditions did not have diabetes addressed in their baseline care plan due to an admitting nurse's oversight in the electronic assessment. This omission resulted in the absence of diabetes-related interventions in the initial care plan, despite the resident's diagnosis and need for glucose monitoring and oral antidiabetic medication. The error was not detected during subsequent reviews by nursing staff and the MDS Coordinator.
A resident with COPD and Alzheimer's Disease received oxygen therapy on multiple occasions, but staff failed to document these administrations in the MAR as required by facility policy. Interviews and other records confirmed the resident's use of oxygen, but the MAR did not reflect this, resulting in incomplete clinical records.
A resident with severe cognitive impairment and multiple diagnoses did not have care plan meetings held with her or her representative for several months, despite facility policy and staff acknowledgment that such meetings should occur at least quarterly. Documentation showed the last meeting attended by the representative was in March, with no evidence of further involvement or notification.
A resident with COPD and Alzheimer's experienced a significant decline, including low oxygen saturation and decreased consciousness. Although the physician was notified promptly, the resident's representative was not informed until a week later, contrary to facility policy requiring immediate notification after such changes.
Three residents did not receive pharmaceutical services in accordance with physician orders and facility policy: one resident received Morphine late due to an LVN's unfamiliarity with scheduled narcotics, another received Tramadol late because of staffing issues, and a third was given Tramadol without a current physician order after a hospital stay. The DON confirmed these actions did not follow policy requiring timely and authorized medication administration.
Staff failed to document the administration of controlled pain medications on the MAR for three residents, despite administering the medications and signing the narcotic sheet. The involved residents had complex medical conditions requiring pain management, and staff interviews confirmed that the omission was due to being busy or distracted, even though they were aware of and trained on the facility's documentation policy. The DON verified that the required documentation was missing from the MARs.
Surveyors found that food storage, preparation, and equipment sanitation practices were not in accordance with professional standards. Dinnerware and cooking utensils were not properly cleaned or maintained, with visible residues and damage. Food items in the refrigerator and freezer were not labeled, dated, or sealed correctly, and some were expired. The walk-in freezer had significant ice accumulation and boxes stacked to the ceiling. The dietary manager was unaware of several food safety requirements, and sanitation of equipment such as steam table wells was inadequate.
A nurse left a medication cart laptop screen open and a report sheet with multiple residents' information exposed, making confidential records accessible to unauthorized individuals. Interviews confirmed staff awareness that this was a HIPAA violation and contrary to facility policy requiring the protection of resident information.
A resident with right-sided hemiplegia, aphasia, and dementia was found with their call light out of reach, despite a care plan intervention requiring it to be accessible. Staff interviews confirmed the call light should have been within reach, and the resident was unable to communicate verbally or by other means. Facility policy required a comprehensive care plan to meet such needs, but this was not fully implemented.
A resident with multiple complex medical conditions and chronic pain did not have accurate documentation of narcotic administration, as the MAR did not match the narcotic sheet for a prescribed pain medication. Staff interviews confirmed that both records are required to be consistent, but the facility failed to ensure this, resulting in incomplete and inaccurate medical records.
A resident with a surgical wound and impaired cognition did not receive proper infection control during wound and incontinent care. The ADON did not follow correct wound cleansing technique or ensure all wounds were treated, and a CNA failed to perform hand hygiene and used dirty gloves while assisting with wound care. The resident's room lacked required EBP signage and PPE, and physician orders were unclear regarding wound care for all incision sites.
The facility did not provide or document written transfer or discharge notifications to residents, their representatives, or the local ombudsman as required. Interviews confirmed that these notifications were not sent, and a review of discharges showed this process was not followed for multiple residents.
A resident with an indwelling Foley catheter was observed with an uncovered drainage bag, leaving urine visible to staff and visitors. Staff interviews revealed confusion about responsibility for placing privacy bags, and the facility's policy required catheter bags to be covered to maintain resident dignity. No recent in-service training on this issue was documented.
A resident with cognitive awareness and physical care needs reported to an LVN that another LVN had physically abused her by throwing her into a wheelchair. The allegation, though reported months after the alleged incident, was not communicated to local law enforcement as required by facility policy and federal regulations. The administrator did not notify law enforcement due to the time elapsed, resulting in a failure to meet mandated reporting requirements.
A resident with a history of impaired mobility and cognition experienced an unwitnessed fall in a facility. Two CNAs found the resident on the floor, assisted her into a wheelchair, and then into bed without notifying a nurse or conducting an evaluation for injuries. The resident later reported leg pain, leading to an X-ray that revealed fractures. The facility's policy required a nurse evaluation before moving a resident after a fall, which was not followed, resulting in delayed medical intervention.
A resident with severe cognitive impairment exited a facility unsupervised due to a new receptionist's failure to properly set the door alarm. The resident, at risk for elopement, was found sitting outside the front door for 3-5 minutes before being redirected inside by a staff member. The incident highlights inadequate supervision and improper door security.
The facility failed to maintain proper sanitation and food safety standards in its kitchen, with issues such as a dirty ice machine, unclean drinking glasses, eroded non-stick pans, and pest control problems. The Assistant DM was unaware of these issues and failed to report them, and the facility's policies on infection control and cleaning were not adequately followed.
The facility failed to maintain essential kitchen equipment, including a walk-in freezer with significant ice build-up and a drooping ceiling, insufficient lighting in the walk-in freezer and refrigerator, and non-functional vent hood lights and exhaust fan. Staff interviews revealed a lack of communication and awareness of these issues, with minimal maintenance records and no invoices for necessary repairs.
The facility failed to follow physician orders for regular weight monitoring for eight residents, leading to potential risks of severe weight loss or gain. The deficiency was due to a lack of systematic monitoring and documentation, as revealed through interviews and record reviews. Staff acknowledged the oversight, which was only addressed in a QAPI meeting after the issue was identified.
The facility failed to maintain effective pest control in the kitchen, with ants found on a prep table and rodent droppings on the floor. Staff interviews revealed a lack of awareness and responsibility for pest control measures, and the facility's pest control logs and policies were not provided. The ADM acknowledged the need for kitchen repairs but was unaware of the extent of the issues.
A resident with Parkinson's disease and other conditions was unable to use the call light due to physical limitations, leading to a deficiency in accommodating her needs. Despite the facility's policy requiring accessible call lights, the resident's inability to use it was not addressed, and there was no specific assessment for call light use. Staff sometimes heard her calling out for help, but assistance during rounds could result in delays.
A resident's request to keep her bedroom door closed for privacy was not honored by the facility staff, despite being documented in her care plan. The resident, who is cognitively intact and has a history of dementia and other conditions, expressed frustration over the noise from the hallway. The DON acknowledged the importance of respecting residents' preferences to prevent emotional distress.
A facility failed to change a resident's oxygen tubing weekly as ordered, posing an infection risk. The resident, with Alzheimer's and Heart Failure, had tubing labeled from weeks prior, despite orders to change it every Sunday night. Staff interviews confirmed the tubing should be changed weekly, and the facility's policy supported this practice.
A medication/treatment cart was found unlocked at the nurse's station, accessible to residents. LVN B left the cart unlocked while attending to a resident emergency, and LVN F confirmed forgetting to lock it. Both acknowledged the importance of keeping carts locked, as per facility policy. The DON reiterated that carts should be locked when unattended.
Failure to Ensure Call Light Accessibility for Non-Communicative Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by facility policy and the resident’s care plan. The resident was an adult female with acute and chronic respiratory failure with hypoxia, tracheostomy, dependence on supplemental oxygen, hemiplegia and hemiparesis following cerebral infarction, and a diagnosis of persistent vegetative state. A quarterly MDS indicated she was rarely or never understood, unable to answer cognitive questions, and required maximum assistance with all ADLs, with mobility not assessed due to her vegetative state. Her care plan identified an inability to communicate with others related to the persistent vegetative state and included an intervention for a specialized call device that was easier to operate. During observation, the resident was found in her room with no call light within reach; the call light was clipped to itself behind her on the wall. Staff interviews confirmed that the LVN and CNA who had repositioned the resident were unaware or unsure why the call light was not placed within reach, despite acknowledging that call lights were expected to be within reach of all residents, including this resident. The DON also stated that all residents, including this resident, were expected to have a call light pinned on the bed, blanket, or within reach, and referenced the resident’s potential to go into respiratory distress. Facility policy on the resident call system required that the call light be positioned within reach of the resident and accessible while in bed or other sleeping accommodations, and that if a resident could not use the call light, the nurse must determine an adequate alternative.
Failure to Include Diabetes Mellitus in Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for effective and person-centered care for a newly admitted resident with multiple diagnoses, including type 2 diabetes mellitus with diabetic chronic kidney disease and heart disease. Upon admission, the resident's baseline care plan assessment did not indicate the presence of diabetes mellitus, as the corresponding box was not checked by the admitting nurse. As a result, the baseline care plan did not include interventions or care planning for diabetes management, despite the resident's documented diagnosis and need for oral antidiabetic medication and glucose monitoring. Interviews with facility staff revealed that the admitting nurse was aware of the resident's diabetes diagnosis but inadvertently failed to select the appropriate option in the electronic assessment, which led to the omission of diabetes-related care planning. The process for developing baseline care plans involved the admitting nurse completing the assessment, followed by review and sign-off by an RN, and a final review by the MDS Coordinator. However, the error was not identified during these reviews, resulting in the resident's baseline care plan lacking critical information regarding diabetes care. The deficiency was identified through record review and staff interviews, which confirmed that the baseline care plan did not reflect the resident's admitting diagnosis of diabetes mellitus. The facility's policy required completion and implementation of a baseline care plan within 48 hours of admission to promote continuity of care and resident safety, but this was not achieved in this instance due to the oversight during the admission process.
Failure to Accurately Document Oxygen Administration in MAR
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with diagnoses of COPD and Alzheimer's Disease. Specifically, the Medication Administration Record (MAR) did not reflect the administration of oxygen therapy on nine occasions during August, despite other documentation and staff interviews confirming that the resident received oxygen via nasal cannula on those dates. The resident had an active physician order for oxygen at 2 liters/minute as needed for shortness of breath, which was not properly documented in the MAR. Interviews with the ADON and DON confirmed that the resident intermittently used oxygen, particularly after an episode of shortness of breath, and that it was the responsibility of nursing staff to document all medication and treatment administration in the MAR. Facility policy also required documentation of all administered medications and treatments. The lack of accurate documentation in the MAR resulted in incomplete clinical records for the resident.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were involved in the development and implementation of her person-centered care plan. Record review showed that the resident, an elderly female with diagnoses including COPD and Alzheimer's Disease and a severely impaired BIMS score, had a care plan developed with interventions updated throughout her stay. However, documentation revealed that the last care plan meeting attended by the resident's representative was in early March, and there was no evidence of subsequent meetings or notifications to the representative after that date. Interviews with facility staff confirmed that no care plan meetings had been held with the resident or her representative since the new social worker began employment in mid-July. The social worker and administrator both acknowledged the importance of involving the resident and representative in care planning and stated that meetings should occur at least quarterly. Facility policy also required advance notice and participation of the resident and representative in care planning conferences. Despite these requirements, the facility did not provide evidence of such involvement for the resident after the March meeting.
Failure to Immediately Notify Resident Representative After Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative (RP) following a significant change in the resident's condition. The resident, an elderly female with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's Disease, experienced a sudden decline on the morning of 08/14/25, including abnormal vital signs, decreased intake, functional decline, decreased level of consciousness, low-grade fever, shortness of breath, non-productive cough, abnormal lung sounds, and cold symptoms. Her oxygen saturation was measured at 82%, and she was administered oxygen via nasal cannula as per physician orders. The change in condition evaluation was completed by the ADON, who documented that the physician was notified on the same day. However, the RP was not notified of the resident's change in condition until a week later, as indicated in the documentation and confirmed by interviews with the RP, ADON, and DON. The RP only learned of the incident after requesting medical records following the resident's discharge. The facility's policy requires immediate notification of the resident, physician, and representative in the event of a significant change in condition, but this protocol was not followed in this instance.
Failure to Provide Timely and Authorized Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three residents. In the first instance, a resident with chronic pain and multiple comorbidities, including peripheral vascular disease and hemiplegia, did not receive his scheduled dose of Morphine at the prescribed time. The medication, ordered to be administered twice daily at 9:00 am and 5:00 pm, was instead given at 7:57 pm by an LVN who was unaware of the scheduled time and cited being busy and unfamiliar with the number of scheduled narcotics. The LVN acknowledged not following facility policy, which requires medications to be administered within a one-hour window of the scheduled time. A second resident, who had severe cognitive impairment and multiple diagnoses including vascular dementia and hemiplegia, also did not receive her scheduled dose of Tramadol at the prescribed time. The medication, ordered for administration twice daily at 9:00 am and 5:00 pm, was given at 8:00 pm. The responsible LVN was not available for interview, but the DON confirmed the medication was administered late due to staffing issues, specifically the absence of a medication aide, and that the LVN was responsible for the delay. The facility policy, as stated by the DON, requires timely administration of medications within a one-hour window. In a third case, another resident with a history of heart failure, chronic kidney disease, and diabetes received Tramadol without a current physician order. The LVN administered the medication after the resident requested it, mistakenly believing the order was still active following a recent hospital stay. The LVN did not review the resident's chart prior to administration and did not contact the physician to confirm or obtain a new order. The DON confirmed that the medication was given without an order and that this was not in accordance with facility policy, which prohibits administering medications without a valid physician order.
Failure to Document Narcotic Administration on MARs
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three residents by not documenting the administration of controlled pain medications on the Medication Administration Record (MAR) as required by facility policy and professional standards. For each resident, staff administered medications such as tramadol and morphine, signed the narcotic sheet, but did not record the administration on the MAR. Interviews with the involved LVNs and SDC confirmed that they were responsible for this documentation and acknowledged the omission, often attributing it to being busy or distracted after signing the narcotic sheet. The residents involved had significant medical histories, including chronic pain, peripheral vascular disease, hemiplegia, heart failure, chronic kidney disease, diabetes, and vascular dementia. Despite having care plans and physician orders for pain management, the staff did not consistently document the administration of as-needed pain medications on the MAR, even though they had been trained on the importance of this process and the facility's policy required documentation in both the narcotic sheet and the MAR. The Director of Nursing (DON) confirmed that the staff did not follow facility policy, which mandates that all administered narcotics be documented in two places. The DON also verified that the MARs for the relevant dates were blank, indicating the medications were not recorded as given. Staff interviews revealed an understanding of the importance of proper documentation for resident safety and continuity of care, but the required documentation was still not completed at the time of the incidents.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the kitchen and nutrition room. Observations revealed that dinnerware, including clear plastic drinking glasses and plastic plate covers, were not properly cleaned or dried, with a thick removable whitish substance present and glasses left wet on racks without drainage mats. Additionally, cooking equipment such as non-stick pans and large cooking pots were found to be in poor condition, with flaking coatings, dents, pitting, and dark discoloration. Utensils in the clean bin were dirty, damaged, or chipped, and some were deemed unsafe for use by the dietary manager (DM). Food storage practices were also deficient. Items in the refrigerator and freezer, such as trays of beverages and pitchers, were not labeled or dated, and some food items, including apple juice containers, were found to be expired. Opened boxes and bags of frozen foods were not tightly sealed, and there was a significant accumulation of ice in the walk-in freezer, with boxes stacked to the ceiling. The DM was unaware of several food safety requirements, including the need for labeling, dating, and proper sealing of food items, and acknowledged that expired and improperly stored food could pose a risk to residents. Sanitation of equipment was inadequate, as evidenced by the presence of a flaking, yellow/white substance in all steam table wells. The DM was unable to confirm how often these wells were cleaned. The facility's policies and training records indicated requirements for proper food handling, storage, and equipment maintenance, but these were not consistently followed. The DM admitted responsibility for the kitchen and acknowledged lapses in staff training and oversight. The registered dietician was not available for interview, and ongoing issues with the walk-in freezer were documented in repair records.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records for 7 out of 10 residents reviewed. During observations, a nurse (LVN-D) left a medication cart laptop screen open and unattended, displaying multiple residents' information. Additionally, a report sheet containing multiple residents' information was left face up on the medication cart, accessible to anyone passing by. These incidents were directly observed by surveyors, who noted that the information was visible and could have been accessed by unauthorized individuals. Interviews with the involved nurse, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) confirmed that leaving residents' information exposed is considered a HIPAA violation. The nurse acknowledged awareness of the requirement to lock the computer screen and secure paperwork but stated she was busy and forgot to do so. Facility policy and residents' rights documents reviewed by surveyors also confirmed the expectation that personal and clinical records be kept confidential and not released without consent.
Failure to Ensure Call Light Accessibility for Nonverbal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, including right-sided hemiplegia, aphasia, and dementia. The resident's care plan identified the need for the call light to be within reach as an intervention to reduce fall risk, but during an observation, the call light was found coiled on the floor approximately three feet from the resident's bed, out of the resident's reach. The resident, who was unable to speak and had limited ability to communicate, could only respond to questions with head movements and was unable to indicate how long the call light had been inaccessible. Interviews with staff confirmed that the call light should have been clipped to the bed within the resident's reach, and both a CNA and an LVN acknowledged the importance of call light accessibility, especially for this resident who could not verbally call for help. The Director of Nursing also stated that lack of access to the call light could result in delayed staff response to resident needs. Review of facility policy confirmed the requirement for a comprehensive care plan with measurable objectives and timeframes to meet residents' needs, which was not fully implemented in this case.
Failure to Accurately Document Narcotic Administration in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically regarding the administration of hydrocodone-acetaminophen for pain management. Record review revealed that the Medication Administration Record (MAR) did not match the narcotic sheet, which documented the removal and administration of the medication. The narcotic sheet and blister pack both indicated that a dose was given, but the MAR lacked documentation for the corresponding date and time. Interviews with facility staff, including the Administrator, ADON, and DON, confirmed that both the MAR and narcotic sheet are required to be consistent and accurately reflect when a narcotic is dispensed to ensure proper medication tracking and resident safety. The resident involved had multiple complex medical conditions, including diabetes, necrotizing fasciitis, stage 4 and unstageable pressure ulcers, and was receiving insulin and IV medications. The resident's care plan included chronic pain management with analgesic medications as ordered by the physician. Despite these needs, the facility did not ensure that the MAR was updated to reflect the actual administration times of the prescribed pain medication, as evidenced by the discrepancy on the narcotic sheet and MAR. Facility policy requires accurate documentation and investigation of any discrepancies, but this was not followed in this instance.
Failure to Maintain Infection Control Practices During Wound and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident with a surgical wound. Specifically, the Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist (ICP), did not demonstrate proper wound cleansing technique and did not ensure all surgical wounds were addressed during wound care. Physician orders for wound care were unclear and did not specify care for all four surgical incision areas, resulting in one wound not being treated during the observed wound care session. Additionally, the resident's room lacked Enhanced Barrier Precautions (EBP) signage and appropriate personal protective equipment (PPE) supplies, despite facility policy requiring EBP for residents with wounds. During observed care, a Certified Nursing Assistant (CNA) failed to perform hand hygiene between providing incontinent care and applying a clean brief, and then assisted with wound care without changing gloves or sanitizing hands. The CNA placed a dirty, gloved hand over an uncovered surgical wound throughout the wound care process. Both the ADON and CNA acknowledged these lapses in infection control during interviews, and the ADON confirmed that the resident should have been on EBP precautions but was overlooked. The resident involved had a history of a right hip fracture with surgical intervention, type 2 diabetes, and severely impaired cognition.
Failure to Provide Required Written Transfer and Discharge Notifications
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for resident representatives to ensure safe and orderly transfers or discharges. Specifically, the facility did not send written transfer or discharge notifications to residents, their representatives, or the local ombudsman in a language and manner they could understand. Interviews with the administrator and the ombudsman confirmed that these notifications were not being sent, and the administrator was unaware of the reason for this lapse. The facility's own policy required such notifications and documentation, but these steps were not followed. A review of the facility's discharge report over a three-month period showed 55 discharges to various settings, including acute care hospitals, funeral homes, hospice, other nursing homes, and private homes, both with and without home health services. The facility's policy also required that the reasons for transfer or discharge be recorded in the resident's medical record, but the report indicates that the required written notifications were not provided as stipulated.
Failure to Ensure Foley Catheter Privacy Bag Use for Resident Dignity
Penalty
Summary
A deficiency occurred when a male resident with a history of benign prostatic hyperplasia, bilateral hydronephrosis, and urinary retention was observed with an indwelling Foley catheter drainage bag that was not covered by a privacy bag. The urine in the catheter bag was visible to staff and visitors passing by the resident's room on two separate occasions. The resident's care plan included interventions for catheter care but did not specify the use of privacy bags, and the physician's orders addressed catheter maintenance but not privacy coverings. Interviews with staff revealed confusion regarding responsibility for placing privacy bags, with a CNA stating that only nurses could place them, while an LVN clarified that all clinical staff were permitted to do so. Both staff members and the DON acknowledged that privacy bags are intended to protect resident dignity by concealing urine output. The facility's dignity policy also specified that urinary catheter bags should not be left uncovered. There was no documentation of recent in-service training on this topic, and requested records of such training were not provided by the time of the exit conference.
Failure to Timely Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to local law enforcement within the required timeframe. Specifically, a resident with Parkinson's disease and dysphagia, who was cognitively intact and required assistance with activities of daily living, informed an LVN that another LVN had allegedly thrown her into a wheelchair. This allegation was reported to facility staff on 11/24/2024, but the incident was said to have occurred several months prior, in June 2024. Despite the facility's policy requiring notification of law enforcement for alleged abuse, the administrator did not contact local law enforcement due to the time elapsed since the alleged event. The administrator enacted the facility's abuse protocol by removing the alleged perpetrator from duty and notifying state agencies, but did not notify law enforcement as required. The facility's policy and federal regulations mandate immediate reporting to law enforcement for allegations of abuse, regardless of when the incident is reported. The failure to notify law enforcement was based on the administrator's decision that the time elapsed since the alleged incident did not warrant such notification, despite the policy's requirements.
Failure to Evaluate Resident After Fall Leads to Fractures
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall. The incident involved a resident with a history of impaired mobility, weakness, impaired cognition, and pain, who was at risk for falls. On the morning of the incident, the resident was found on the floor by two CNAs after calling for help. The CNAs assisted the resident into a wheelchair and then into bed without notifying a nurse or conducting a proper evaluation for injuries. The resident later reported pain in her leg to another CNA, who then informed a nurse. An X-ray was ordered, revealing fractures in the resident's left distal femoral shaft and right tibia and fibula. The resident was subsequently transferred to a hospital, where it was determined that the left femur fracture was not fixable, leading to a recommendation for a left above-knee amputation. Interviews with the resident and staff revealed inconsistencies in the accounts of the incident, with the resident recalling a fall and subsequent pain, while the CNAs initially did not report the fall. The facility's policy required a licensed nurse to evaluate a resident before moving them after a fall, which was not followed in this case. The CNAs involved were terminated following an investigation, and the facility took corrective actions to address the deficiency. However, the initial failure to adhere to the policy and properly assess the resident's condition after the fall led to a delay in appropriate medical intervention.
Resident Exits Facility Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to the resident exiting the facility through the front door. The resident, a male with severe cognitive impairment, was at risk for elopement due to confusion, disorientation, and impaired safety awareness. Despite these risks, the resident was able to leave the facility unsupervised and was found sitting on a bench outside the front door. The incident occurred when a new receptionist, who was not properly trained on setting the door alarm, went on break and locked the door incorrectly. This allowed the resident to exit the facility without supervision. The resident was outside for approximately 3-5 minutes before being noticed by a Central Supply staff member, who then redirected him back inside without incident. Interviews with staff revealed that the resident was not displaying exit-seeking behavior and was simply sitting outside enjoying the fresh air. However, the lack of proper supervision and failure to secure the facility's entrance led to the resident being outside unsupervised, which could have posed a risk for injury or accidents.
Facility Fails to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The ice machine was found to have a reddish substance along the ice chute, and drinking glasses were coated with a whitish yellow substance, indicating inadequate cleaning. Non-stick pans were eroded, and pots and pans were dented, which could harbor bacteria. Additionally, ants were observed on a prep table, and there was a significant ice build-up in the walk-in freezer, causing structural concerns. Personal items were improperly stored in food preparation areas, and the lighting in the walk-in refrigerator and freezer was insufficient. Interviews with the Assistant Dietary Manager (DM) revealed a lack of awareness and action regarding these issues. The Assistant DM admitted to not knowing the cause of the substances on the ice chute and glasses and acknowledged the potential health risks to residents. She also mentioned that the kitchen staff followed a daily cleaning schedule, but there were gaps in the cleaning log, and she was unaware of the extent of the ice build-up in the freezer. The Assistant DM also failed to report issues with lighting and pest control, assuming others were already aware. The facility's policies on infection control and cleaning were not adequately followed, as evidenced by the lack of ongoing training and incomplete cleaning logs. The facility's policy required regular training and monitoring of food storage, preparation, and service areas, but these were not effectively implemented. The absence of a section for the ice machine in the cleaning log and the lack of significant training on infection control contributed to the deficiencies observed during the survey.
Facility Fails to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed during a survey. The walk-in freezer had a significant ice build-up attached to the ceiling, causing the ceiling to droop, and the door did not close properly, leaving a large gap. The lighting inside both the walk-in freezer and refrigerator was insufficient, making it difficult to identify contents. Additionally, the vent hood lights were out, and the exhaust fan was not functioning properly, emitting a screeching sound. The air intake and return vents were covered with a thick layer of dark brown/black substance, and the air was directed towards the food holding area. Interviews with staff revealed a lack of communication and awareness regarding the equipment issues. The Assistant DM acknowledged the dim lighting and non-functional vent hood lights but assumed maintenance was aware. The MS admitted to knowing about the ice build-up and the need for new vent hood fixtures but had not taken action. The DM was unaware of the lighting issues and acknowledged the walk-in freezer's poor condition. The ADM, new to the facility, was not informed of the kitchen's repair needs. The maintenance log showed minimal entries, and there were no invoices for repairs to the walk-in freezer or lighting, indicating a lack of maintenance and oversight.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure that eight residents received care in accordance with professional standards of practice and their comprehensive person-centered care plans. Specifically, the facility did not follow physician orders for regular weight monitoring for these residents, which could result in severe weight loss or gain, affecting their quality of life. The residents involved had various medical conditions, including dementia, cerebral palsy, Alzheimer's disease, and diabetes, which necessitated regular weight monitoring as part of their care plans. The deficiency was identified through interviews and record reviews, revealing that the facility did not document weights for the month of June 2024 for several residents. For instance, Resident #4, who had a physician order for monthly weights, did not have a weight recorded for June, resulting in a weight loss of 1.65% over two months. Similarly, Resident #32, who required weekly weights, also had no weight documented for June, leading to a 2.33% weight gain over the same period. These lapses in documentation and monitoring were consistent across the other residents reviewed. Interviews with facility staff, including the DON, Unit Manager, and CNA A, revealed a lack of a systematic approach to ensure weights were recorded as ordered. The DON acknowledged that the facility's electronic patient chart was the only place weights should be recorded, and that CNA A, who was primarily responsible for weighing residents, had fallen behind. Despite verbal communication about the issue, no corrective actions were taken in June, and the problem was only addressed in a QAPI meeting in July. The RD also noted the missing weights and communicated concerns to the administration, but no response was received.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the presence of ants on a prep table and rodent droppings on the kitchen floor. During an initial observation, ants were found on and around a can opener attached to a prep table, crawling across the table and up a wall into a crack. Additionally, rodent droppings were observed on the floor near a hole in the baseboard. Interviews with staff revealed a lack of awareness and responsibility regarding pest control measures, with the Assistant DM unable to confirm the presence of sticky traps or their maintenance. The facility's pest control log and maintenance log were requested but not provided, and the pest control service contract lacked detailed information on prevention measures. The MS stated that the pest control company treated for ants but was unsure about the presence and location of sticky traps. The DM and ADM were also interviewed, with the ADM acknowledging the need for kitchen repairs but unaware of the extent of the issues. The facility's policy on pest control was requested but not received, indicating a lack of documentation and oversight in maintaining a sanitary environment.
Failure to Accommodate Resident's Call Light Needs
Penalty
Summary
The facility failed to provide services with reasonable accommodation of resident needs and preferences for a resident who was unable to use the call light due to physical limitations. The resident, who had a history of Parkinson's disease, neuralgia, neuritis, lack of coordination, muscle weakness, and a history of falling, was observed in bed with the call light wrapped on the right-side rail, which she could not physically use. Despite attempts to use the call light, the resident was unable to grasp and press it for assistance, which was confirmed by the Director of Nursing (DON) during an observation. Interviews with staff revealed that the resident had been unable to use the call light since admission, and staff sometimes heard her calling out for help or relied on other residents to alert them. The Administrator acknowledged that the resident's condition had changed, possibly due to seizures, affecting her ability to use the call light. However, there was no specific assessment for call light use, and assistance was provided during rounds, which could result in delays. The facility's policy required that call lights be within reach and accessible to residents, with alternative solutions provided if a resident could not use the standard call light. Despite this policy, the resident's inability to use the call light was not adequately addressed, and there was no procedure or policy to ensure residents could use the call light. The resident's care plan and assessments did not reflect her inability to use the call light, leading to a deficiency in accommodating her needs and preferences.
Failure to Respect Resident's Privacy Preferences
Penalty
Summary
The facility failed to ensure the privacy of a resident who had requested that her bedroom door be kept closed. This deficiency was identified during a survey where it was observed that the resident's door remained open wide over several days. The resident, who is cognitively intact with a BIMS score of 13, expressed her preference for the door to be closed due to noise from the hallway. Despite this preference being documented in her care plan, the staff did not adhere to her request, leading to her feeling angry. The resident's care plan, which was last revised in June 2024, clearly indicated her preference for the door to be closed after care, food delivery, and any interactions. The Director of Nursing acknowledged that residents' preferences should be respected and that failure to protect privacy could lead to emotional distress. The resident's medical history includes dementia, stroke, depression, anxiety, and limited range of motion, and she requires assistance with various daily activities.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as ordered. The resident, an elderly female with Alzheimer's Disease and Heart Failure, had an active order to change the oxygen tubing and nebulizer circuit every Sunday night shift. However, observations on multiple occasions revealed that the tubing had not been changed since the label dated 06/16/2024, despite the order starting on 05/05/2024. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the tubing should be changed weekly and dated accordingly. Both acknowledged that failure to change the tubing as ordered could lead to the resident becoming sick from dirty tubing. The facility's policy on oxygen administration also stated that oxygen supplies should be changed weekly and labeled with the date when set up or changed.
Unlocked Medication Cart Found at Nurse's Station
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a locked treatment cart, as observed during a survey. An unlocked medication/treatment cart was found by the nurse's station, with its drawers facing outward, making medications easily accessible. This occurred while a staff member, LVN B, was present at the nurse's station, and two residents were nearby. The surveyor was able to open the drawers and access multiple medications and treatment supplies. Interviews with LVN B and LVN F revealed that the cart was left unlocked due to an emergency situation involving a resident who was bleeding. LVN B admitted to leaving the cart unlocked after retrieving supplies to assist the resident. LVN F confirmed that she had forgotten to lock the cart in the rush to attend to the resident. Both LVNs acknowledged that the treatment/medication carts should be locked at all times to prevent unauthorized access. The Director of Nursing (DON) also stated that carts should be locked when unattended, even during emergencies. The facility's policy, dated 1/1/22, mandates that medication carts must always be locked when out of sight or unattended.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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